Key Responsibilities and Required Skills for Health Information Technician

🎯 Role Definition

We are seeking a detail-oriented Health Information Technician (HIT) to manage, analyze, and safeguard patient health information and medical records. The Health Information Technician is responsible for accurate medical record creation, coding and abstracting clinical documentation, processing release of information requests, maintaining electronic health record (EHR/EMR) integrity, and ensuring HIPAA-compliant handling of protected health information (PHI). This position supports revenue cycle, quality reporting, internal/external audits, and clinical documentation improvement (CDI) initiatives while collaborating with clinical, billing, and compliance teams to optimize health information workflows.

📈 Career Progression

Typical Career Path

Entry Point From:

Medical Records Clerk / Medical Office Assistant
Patient Registration Specialist
Clinical Unit Secretary

Advancement To:

Senior Health Information Technician
Medical Coding Specialist / Certified Coder (CCS, CPC)
Health Information Manager / HIM Supervisor

Lateral Moves:

Clinical Documentation Improvement (CDI) Specialist
Release of Information Coordinator
Revenue Cycle Analyst

Core Responsibilities

Primary Functions

Maintain and update accurate patient medical records in electronic health record (EHR/EMR) systems (e.g., Epic, Cerner), ensuring completeness, legibility, and compliance with facility documentation standards and legal retention policies.
Abstract clinical data, including diagnoses and procedures, from physician notes, operative reports, lab/imaging results, and discharge summaries to support coding, billing, and clinical quality reporting.
Assign and validate ICD-10-CM, CPT, and HCPCS codes consistent with current coding guidelines, payer rules, and organizational coding policies to support accurate claims submission and revenue integrity.
Conduct concurrent and retrospective chart reviews to identify missing documentation, coding gaps, and opportunities for clinical documentation improvement (CDI); prepare and communicate query requests to providers in accordance with compliant query processes.
Process and respond to Release of Information (ROI) requests, subpoenas, and legal requests for medical records, ensuring appropriate authorization, stamping, redaction, and timely delivery while maintaining HIPAA compliance.
Perform regular record quality audits and reconciliation of medical records to detect incomplete charts, duplicate records, mismatched patient identifiers, and other discrepancies; coordinate corrective actions with clinical teams.
Support revenue cycle processes by ensuring that coded encounters, discharge summaries, and physician signatures are complete prior to claim submission and by resolving documentation-related denials and rejections.
Utilize health information systems and reporting tools to extract, validate, and submit clinical quality measures (e.g., HEDIS, MIPS), meaningful use/Promoting Interoperability data, and other regulatory reports.
Ensure protection of patient health information (PHI) by following HIPAA/privacy regulations, applying confidentiality safeguards, and participating in privacy and security audits and trainings.
Reconcile and maintain record retention schedules, archiving inactive records, and coordinating secure destruction according to state and federal regulations and institutional policy.
Coordinate with billing, utilization review, case management, and clinical departments to clarify documentation, resolve discrepancies, and support safe discharge and billing accuracy.
Support patient access functions, including verifying identity for record release, assisting patients with requests for copies of records, and providing guidance on fees and timeframe for record release.
Identify and escalate potential fraud, abuse, or PHI breaches, participate in incident investigations, and assist with remediation and reporting in collaboration with compliance and privacy officers.
Assist with EHR build, testing, and optimization projects by participating in user acceptance testing (UAT), documenting workflow requirements, and training end users on HIM-related processes and best practices.
Maintain current knowledge of coding, billing, and documentation standards by participating in continuing education, certification maintenance (e.g., RHIT, CCS), and professional HIM organization activities.
Prepare and deliver monthly and ad-hoc HIM performance dashboards and metrics (e.g., chart completion rates, coding accuracy, ROI turnaround time) to leadership and stakeholders to drive continuous improvement.
Support internal and external audits by preparing records, abstracted data, coding justifications, and responses to auditor queries; implement audit recommendations to strengthen HIM operations.
Index and file paper-based medical records and attachments into the EHR, ensuring that scanned documents are accurate, properly labeled, and linked to the correct patient encounter.
Train and mentor junior HIM staff and cross-functional employees on chart completion processes, proper use of EHR templates, compliant release of information procedures, and coding/documentation basics.
Manage patient identifier errors and perform patient record merges/splits with strict adherence to patient safety, data integrity, and privacy protocols; document actions and authorization for audit trail.
Facilitate interdepartmental communication for clinical documentation improvements, coding clarifications, and workflow changes to reduce denials, improve revenue capture, and enhance patient care continuity.
Support population health and analytics initiatives by ensuring high-quality clinical data capture, standardized documentation, and coded problem lists that enable accurate reporting and care coordination.
Participate in multidisciplinary meetings related to quality, risk, billing, and compliance to represent HIM perspectives, recommend process changes, and help implement HIM-driven improvements.

Secondary Functions

Provide subject-matter expertise to IT teams and vendors during EHR upgrades, interface implementations, and data migration projects to ensure HIM requirements and data integrity are preserved.
Assist with special projects such as chart abstraction for research, registry submissions, and clinical trials by applying consistent data capture and documentation standards.
Support coding and documentation education programs for providers and clinical staff, creating job aids, tip sheets, and targeted training sessions to reduce documentation deficiencies.
Serve as backup support to Patient Access and Medical Records front-line staff during peak periods, ensuring uninterrupted ROI processing and timely patient inquiries.
Participate in disaster recovery and business continuity activities related to medical records access, ensuring availability of critical patient information in emergent situations.

Required Skills & Competencies

Hard Skills (Technical)

Proficient in Electronic Health Record (EHR/EMR) systems such as Epic, Cerner, Meditech, Allscripts, or similar; strong navigation, documentation, and troubleshooting skills.
ICD-10-CM, CPT, and HCPCS coding proficiency with demonstrated accuracy in inpatient and/or outpatient settings.
Experience with release of information (ROI) workflows, authorization verification, redaction practices, and legal subpoena handling.
Familiarity with health information management systems, document imaging/scanning, and record indexing best practices.
Knowledge of HIPAA privacy and security regulations, state record retention laws, and regulatory compliance requirements.
Ability to abstract clinical data for quality measures, registries, and payer submission; skilled in accurate clinical data extraction and validation.
Experience conducting chart audits, coding reviews, clinical documentation improvement (CDI) support, and preparation for external audits.
Proficient with Microsoft Office Suite (Excel for reporting and pivot tables, Word, Outlook) and reporting tools or BI platforms used for HIM metrics.
Understanding of revenue cycle fundamentals, claim lifecycle, denial management, and how documentation impacts reimbursement.
Experience with patient identity management, record merges/splits, and ensuring accurate patient matching and data integrity.
Familiarity with healthcare terminologies and classifications (SNOMED CT, LOINC) and interoperability standards (HL7, CCD).
Basic SQL or query/reporting experience (preferred) for ad-hoc data pulls and quality reporting.

Soft Skills

Exceptional attention to detail and strong organizational skills to manage high volumes of medical records and time-sensitive requests.
Strong written and verbal communication skills for interacting with clinicians, patients, legal teams, and cross-functional stakeholders.
Critical thinking and problem-solving aptitude to investigate documentation issues, reconciliation tasks, and complex record requests.
Ability to prioritize tasks in a fast-paced, deadline-driven healthcare environment while maintaining quality and compliance.
Customer-service orientation with empathy for patients and internal customers when responding to record requests and education needs.
Adaptability and willingness to learn new systems, workflows, and regulatory requirements as HIM practices evolve.
Team player who collaborates effectively across clinical, IT, billing, and compliance teams to achieve organizational goals.
Ethical judgment and professionalism in handling sensitive PHI and confidential information.

Education & Experience

Educational Background

Minimum Education:

Associate degree in Health Information Management, Health Information Technology, Medical Records, or a related allied health program; OR high school diploma/GED with 2+ years of direct HIM/medical records experience.

Preferred Education:

Associate or Bachelor's degree in Health Information Management or Health Informatics.
Professional certification such as RHIT (Registered Health Information Technician), CCS, CPC, or CCA preferred.

Relevant Fields of Study:

Health Information Management
Health Informatics
Medical Records Technology
Clinical Coding / Medical Billing
Healthcare Administration

Experience Requirements

Typical Experience Range: 1–5 years of health information, medical records, or coding experience in a hospital, clinic, or health system setting.

Preferred: 2+ years of experience with EHR systems (Epic, Cerner), hands-on coding experience (ICD-10/CPT), ROI processing, and demonstrated success supporting audits, quality reporting, or revenue cycle initiatives. Certification (RHIT, CCS/CPC) and prior exposure to clinical documentation improvement (CDI) or coding audit programs are highly desirable.